Application of Clinical Decision Analysis to Audiological Tests

Abstract

This paper is the first in a series of three concerning audiological tests and test batteries designed to differentiate cochlear from retrocochlear site-of-lesion. This paper concentrates on the techniques of clinical decision analysis with particular application to audiology. Those principles of clinical decision analysis which are most relevant for the audiologist are presented. Several techniques for measuring test performance are described and evaluated. In addition, this paper considers the problem of comparing test performance to determine the superior test.Traditionally, audiologists have used specialized tests to help determine the location of pathological conditions in the auditory system. When determining site-of-lesion, the audiologist has the responsibility to appropriately select, administer, and interpret these tests. Unfortunately, many audiologists do not have a coherent theoretical basis for dealing with the probabilistic nature of these tests, an accurate measure of the performance of these tests, or a logical and effective strategy for combining these tests into a test battery.Diagnostic tests are not unique to audiology; professionals in many health related areas face similar difficulties when using tests. Fortunately, effective techniques, called clinical decision analysis, do exist for evaluating the performance and utility of diagnostic tests. While many publications3.7.8-10. 12.17.18.20 have described clinical decision analysis and its application to medicine, there has been limited application to audi01ogy.l~ Only recently have more sophisticated techniques been applied to audiological tests.5.6. This paper is the first in a series of three concerning audiological tests and test batteries. The objective of this paper is to apply clinical decision analysis specifically to audiology so that the audiologist will have techniques for evaluating the performance of diagostic tests and for understanding the probabilistic uncertainties associated with these tests. The second paper evaluates audiological test performance based upon published clinical data.2' The third paper provides the audiologist with the conceptional framework for formulating and evaluating the audiological test battery.20 These three papers provide the essential information the audiologist needs to effectivly use audiological tests. CLINICAL DECISION ANALYSISClinical decision analysis (CDA) is a systematic approach to decision making under conditions of uncertainty.22 CDA is necessary because no audiological test is perfect and because certain "costs" are associated with clinical decisions. CDA permits us to make intelligent decisions by recognizing the probabilistic nature of tests and the consequences of error.To simplify our discussion of CDA we will make certain assumptions. First, we will consider only audiological tests which differentiate cochlear and retrocochlear lesions, and we restrict retrocochlear lesions to mean abnormalities of the cerebellopontine angle (CPA) including the VIIIth nerve. We assume that only two s...

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